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Yes, it's clear. Good. OK, so we speak today about the gait examination and if we have a chance, we'll go to uh speak about Bina or flat foot. Uh This is where they come from. Its head of the hospital is an elective hub in Asco to North East London. And this is the uh youtube channels for myself and for Ortho beer and the, the, the video will be available on both of them. Once we finish the session, good to speak about the gait and understanding the gait is very, very important. It's not just because the basic knowledge is an important, basic knowledge, but as well as um it's a, it's a way to diagnose a lot of conditions in your uh foot and ankle clinic. So for the exam, there is good for part A 5 to 6 questions about gait or gait related problems. And for part B, gait is very important to comment on in the intermediate and you may have one of the shortest patients about gait. So gait is so important for all um FRSS part A and part B and as well, it's very important for, for basic knowledge. It's very important later on in your practice because um it's no way to diagnose a foot and ankle problem without understanding what's the problem with the gait. So to understand the gait will speak specifically about these points, so we'll speak about definitions. Prerequest is for a normal gait, um some biomechanical principles and uh we analyze the gait as kinematics kinetics and assessment and then it would end by common differential diagnosis and examples for abnormal gait. So what's gate? So this definition is very, very important, gait is an energy efficient translatory progression of your body as a whole due to coordinated smooth movement of body segment. So to have a normal gait, your body should progress effectively in a translation movement as energy efficient as possible with normal coordinated smooth movement of the body segment, depending mainly on eccentric contraction and as much as possible on the ground action force. And from here, we can understand what's abnormal gait. So abnormal gait is either it's on smooth gait, it's energy inefficient. There is whole body progression or it's uncoordinated gait. So uh when we speak about the normal gait, we'll go through definitions, prerequisite biomechanical principles. So to understand the definitions, you need to understand um what is step and um with the step, what is tried and of of what is tried and what's what the types of movement. OK. So as you can see from, from uh this picture, so a ST lens is the is the distance between he strike of 1 ft to the he strike of the other foot. But if we speak about the he strike of 1 ft to the hit strike of the same foot, we speak about stri so one step means from here strike of 1 ft to the head strike of the other foot and one, so a step and one side is the hi hi strike of 1 ft to the head strike of the other foot. Then you have the, the cuttings, which is the rate of your movement, the rate of your gait. Then you have the foot progression angle which is the angle between the mid axis of the foot and the line of normal line of progression. Then you have two faces of the gate stands face which mean the foot is flat on the ground or touching the ground and a swing face which means the foot is off the ground. So whenever your foot is off the ground, this is the swing face for this foot. And whenever your foot is touching the ground, this is the stands face of this foot. Then this movement goes in three directions as any, any movement in three blanes axial plane which is a rotational blane, the rotational blane uh in the clonal side, a rotational blane in the sagittal side. So rotation, sagittary rotation, coronary and axia movement in the in the axial plane to have a normal gait you have to have a balancing foot. So balancing foot means the foot is flat on the ground. All the muscles and ligaments are working and the, the, the tibia is steady on the talus and the tail is steady on the calcium and the calcium. Uh it has a normal relation with the mid foot. You have to have a good foot clearance means you can easily clear your foot while you're walking during the swelling phase. If you have any problem with clearing your foot during the swelling phase, you will have an abnormal gait, you have to have a normal foot position. So when you hit a strike with your foot, then float your foot, then go for a flat foot. Your foot is steady on this position and the position of your foot is normal. You have to have an adequate stance to have a normal gait. You cannot. So juggling or running is different than normal gait. It's not a normal gait. But to have a normal gait, you have to have an adequate stance in a normal coordinated manner and it must be energy pre be preservative or uh conservative. This is the idea of a normal gate or the request is to have a normal gate. So to have a normal gait, you have to have a balanced foot, you have to have a normal foot clearance. You have to have a normal foot position. You have to have an adequate stimulant and you have to have an energy uh conservation. When we start to speak about the gate, you need to understand that for every moment, you have to have a full foot on the ground. How do you understand this? When as you hear your hear is striking by, if, if we suggest this is the left foot. So you hear is striking by the left foot. The time you hear is striking by the left foot, you're toing off by the other one. So if you calculate what is from your body on the ground is a 1 ft, one full foot, when you go to the loading face and the flat foot. So the whole right foot is on the ground, this means the whole left foot is off. Then the it comes to the other side. When the left foot start to hit a strike, then the right foot will be coming off the ground in the two off state and go again for the left foot on the same side and then the swing face. So through all the gate cycle, one full foot of your, of your foot will be touching the ground, either it is a full foot right or left or bar from the right and bar from the left. You need to understand this very well. You touch the ground by 1 ft. Either this 1 ft is one full foot right or left or it is a apart from the right and bar from the left, you cannot hit a strike by two by 2 ft, you cannot two off by 2 ft. You cannot feel that foot by 2 ft unless you are standing. But in a gait, whatever you, you remove from the left foot from the, you, you touch with the left foot in the ground, you remove it from the right foot from the ground and you walk on the 1 ft. Number two, the energy ation or energy to preserve an energy while walking, you would be as much as possible on the ground reaction force and on eccentric contraction of the muscle, you understand that all, all of us know from the basic science. Concentric contraction means the muscle shortened, shortens and eccentric contraction means the muscle lenses. So both of them, the muscle goes into action. If the muscle, if the action of the muscle add to short eee end by shorten. So we call concentric contraction. And if the contraction of the muscle end by lengthening the muscle, this is an eccentric contraction and the eccentric contraction of the muscle is an energy preservative way. So the most energy efficient way of muscle contraction is to contract eccentrically based on stopping its lengthening like. And to understand, I'm, I'm not sure if you already know this. So if you do, if you, if you go to the bicep screw, you know, with the bicycle, this is a contraction and concentric contraction. And if something IB on my hand and the biceps is stop the lengthening of the biceps. This is called eccentric contraction. So concentric contraction means action or uh or energy of the muscle is to shorten and eccentric means action of the muscle is to stop lengthening. So when your muscles are acting in eccentric condition, it is preserving energy. Then the ground reaction force is basically the as, as we understand from the third law of nein that for every action, there is a counteraction which is the same in intensity and opposite in direction. This is the third law of Newton from the third blow new. We understand that when you hit the ground by your foot, the ground will be exerting the same force in intensity and in a different direction, otherwise your foot will sink inside the ground. So when you push on the ground by your foot, the weight you put on this side have a similar ground action force by the in the same intensity. But in the opposite direction, as you see on the right side, and this go action force actually has been given to you from the he just to make you walk passively. So in any action with the, any, any, any energy come from the g reaction force, you don't spend any energy on it. That's why the gait, the normal gait is an energy efficient reaction. So uh like you see, if you hear a strike, the ground action force is going beyond your ankle. So normally it's trying to, to uh blunt, to flex your ankle. So your blunter flex without bending, uh any, any energy because the ground action force is doing that for you at the same time. Not to do this uh um aggressively or to, to slab your foot on the ground. Here, the uh tibialis anterior will work eccentrically just to keep your foot, don't allow the foot to lengthen a lot. So don't allow the foot to slap the ground. So to have an efficient gait you underneath, to understand the three principles, you always walk on 1 ft, you're walking with energy preservation mode, which means all your muscles are acting in eccentric contraction rather than concentric contraction. And again, concentric contraction means the muscle act is shortening and eccentric contraction means the muscle is stop itself from lengthening. And this is the, this is the muscle work and you depend a lot on the ground reaction force, which is the best force moving your joints. And this ground reaction force cost you no energy and it plays the main important driving force in A G. Then you need to understand the foot. Rockers. Rockers mean the foot that where, where the foot hits the ground. And you normally in a normal gate has 3 ft rockers. Firstly, the heel rocker. So rocker, the, this is the first you touch the ground with is your heel. Then from the heel rocker, your body start to go and move, then the foot start to be loaded. Then you go to the second rocker, which is the anchor rocker. And then from this anchor rocker, you start to go to the third rocker when you throw off, which is the 4 ft rocker. So when you have a look on the left side, the first thing is to touch the ground is the heel. The movement at that stage is coming from blunt flexion of the ankle or passively dorsiflexion of the uh distal tibia. Then the ankle rocker when you load the whole foot, then the forefoot, roer when you elevate the heart, when you start to two off and the foot is coming off the ground and all your root is going through the forefoot and you lose every rocker in certain baso though with the heel hair rocker, if you have limited blunt flexion of the ankle, you cannot blunt to flex your ankle or you cannot dorsiflex your ankle. When you have an ankle arthritis, you will lose the he roer because with heel arthritis, it doesn't allow ankle to go in a passive dorsiflexion. And it doesn't allow the ankle to smoothly blunter flex with limited dorsiflexion and blunter flexion. You will lose the heel broker. That's why the patient with ankle arthritis will be losing the heel. Then the ankle rer you look mainly the whole foot. And specifically when you have a normal arch is the midfoot that's why the patient with midfoot arthritis is trying to reduce as maximum as he can from the ankle rer. So the anchor rer is nearly nothing because he want to shift from a heel rocker over the ankle to a full foot rocker over the 44 ft without losing the midfoot. So the patient with midfoot arthritis will be losing the ankle rer same as ankle activation with ankle arthritis. 4 ft rooker is when you have any painful forefoot condition, you try as much as you can to move from anchor Rocker to the next foot here, rocker. So you try to, to shorten or minimize your 4 ft rooker stage. So the foot rooker is the importance of the foot rookers. It gives you a clue where is the pathology in the ankle, foot and ankle. Then when you have a look on the foot unit, you understand that we normally, as we explained in the last lecture. So normally you have some degree of physiological valgus which goes into varus with the movement and we have arches of our foot media in a lateral between and transverse arch. And if you normally have that, you will have this shape of the foot or uh foot pressure on the ground. If you have a flat foot or low arch, you will, you all your foot will be on the ground. And if definitely you have a Cava or high arch, you will be overloading just the troo, which is the forefoot and the heat. Then when you look on this picture, you understand that according to the gate cycle, first thing from you to touch the ground is the hill. Then the this is the way of the weight bearing. Then the weight bearing goes from this side over the 50 m tarsal, then transfer to the first metatarsal head. Then this is how, how your no foot is normally um uh loaded. This pattern is lost when you have an arch flat or an arch, high arches. So with any ba in the hind foot, which is Cavovarus or base planus, most conditions and I, I'm sorry, base C or base planus, this condition will be lost and you will be losing certain points of the of of the foot other than the others. Same if you have some tightness in your calf muscles and you're overloading your full foot, this pattern of food distribute uh of weight distribution will not be there. So the normal weight distribution over the foot starting with heat strike, then move over the lateral border, basal fifth, then go straight to the head of first head of first. And this is how the normal uh weight bearing happens on the foot in a normal shape in a normal foot. That's why if we go back, that's why we said that you have, you have to have a foot position, normal foot position without a normal foot position. Weight distribution over the foot or weight loading over the foot will not be that that normal battle. And this is where the problem will happen. The area. The understanding of tibial rotation, we agreed last time that the talus is working as a hinge, which it changed the movement, the axial movement, axial rotation of the distal tibia into a coronal rotation into and in the foot. And normally you need to understand that with heel strike, when you heal a strike, then your foot is blunt reflexing. This foot is going to loot is blunt reflexing. Actually, your tibia is internally rotating. And when you move all your foot moves to the forward, the tibia tibia continue to internally rotate at the same time, internal rotation of the tibia equal external rotation of the foot. So the foot, as we agreed, last time with external rotation of the foot and vuls the the the shoulder joint, the tailor and continue tubo, they become better in the same plane. And that's why it makes your foot subbing. So it can easily accumulate the ground once you go to to off in this stage, when you're towing off, so your foot is more uh your tibia is extend, rotating because your foot is internally rotating uh or a ducting. And when the foot is a ducting, this gets in the teron in a different brain than the calo, then your foot is rigid. And when your foot is rigid is a no nice lever arm for your body to move. You need to understand this very well. Distal tibia is rotating in the axial plane, foot is rotating in the coronal plane. When you move, once you hit a strike your tibia start to internally rotate, your body starts to atten rotate, including the distal tibia, internal rotation of the of the, of the tibia equal external rotation or vuls of the foot with external rotation of vargas of the foot because of the subtalar configuration, as we agreed last lecture, your foot, midfoot joint, which is the shoulder joint will be in the same plane. So the foot will be sub will be easily accommodating the ground during your losing face. In this picture, when you go to off fluid and you're going to two off, your foot is moving internally and the this tibia is moving externally moving internally of the of the foot means the foot gets more abduction and more CS. So the midfoot joint, the shoulder joint, the ankle can void will be in different blanes. And when they are in different brain, the foot is rigid. That's how it ma how, how it makes a normal lever to make your foot push forward. The knee flexion extension is a very, very, very difficult area to understand, be very, very, very uh uh giving me the maximum attention. You can to understand the knee flexion extension. You need to understand that when you hear a strike, the ground action force is coming from behind your ankle and going in front of your knee. So normally what it's doing is is blunt reflexing your ankle and flexing and extending your knee. Once you start to move forward, once your body starts to move forward, the ground reaction force line is fixed, doesn't move. So from the back of the ankle, front of the knee, the knee moves forward. So the ground reaction force become behind the knee. So from a an extending move to the knee to a flexing moment of the knee, that's why after you lose your forefoot, your knee is, is going to flex. And if you don't have the soleus muscle, stopping your knee from more flexion, it will end by you falling on the ground. That's why the soleus is very, very, very important to coordinate your gait to do what we call knee flexion extension coordination or knee flexion extension coupling, what we call the knee flexion soleus coupling. And that is what's missed in the C dation. That's why the C dation always lost the balance. And four again, you hit a strike when you hit a strike, the ground reaction force is going be behind your ankle in front of your knee and behind your hip. So at this stage, the the ground reaction force is extending for moment over the knee, once you flat your foot on the ground and loot and then your body starts to move forward the ground action, force line doesn't change, it becomes behind your knee rather than front of your knee. So it becoming a flexing moment and aiming to flex your knee, nothing to stop your knee from flexing until the pelias starts to come into action. If the soleus is weak or not in action, you will continue flexing until you fall. But because Soleus lost, I gave us Soleus to stop the knee from ex ex extensive flexion. So allow you to go to the next stage, which is too off. That's why you don't fall. That's why your gait comes to be coordinated and normal. And if you lose the cele for any reason, like you have ACB. And uh the most common example is the CB patient. If you lose the soleus co coupling, knee flexion, celeus coupling or knee flexion extension coupling, the end will be that you have to support your knee from the start or you have to be given a um a knee brace, knee, ankle foot or so this to stop your knee from flexing more than enough. And for you to, to go with a normal pain again here, strike moment, arm from the ground action force behind the ankle. So blunter fixing the ankle and extending the knee and fixing the hip, extending your hip. I'm sorry. Once you lose your foot, your, your body is moving forward, distal tibia is moving forward, then the ground reaction force line is still the same. But the knee now become in front of the, of the ground reaction force line. So the ground reaction force line is in flexing the moment to the knee. So this is makes your knee to flex and you, if you continue moving forward, you will be falling. What stops your knee from ex ex extra flexion or more flexion is your so less which stops the knee from flexion and allow you to go to the next step which is too off Sam. If you check the question, this is a very important. These 22 pictures is the most important that you will not get it from any any any any like normal reading. If anyone need me to repeat it, I'm happy to do the, the tibia rotation and the knee flexion extension coupling. They are very, very important. Any questions? No questions. Nothing. Yeah. No, no. OK. That's perfect. OK. The least and the, the, the least important and the least for you to understand is how the, the pelvis move. But you need to understand it's a very coordinated movement in three planes. So the pelvis moves to the front and the back moves from side to side and rotate, moving from pelvis drops by seven degree. You understand this is the idea behind the trend and back test. So every time you move, every time you unload the pelvis by you lifting one leg from the side, the abductor on the other side starts to move. That's why your pelvis starts to drop seven degrees. Then the abductors wall it back up. At the same time, your pelvis moves four degrees and the, and the rotates 10 degrees between both sides to make this a shape coordinated movement of the pelvis to allow you to, to go with a normal gait. Don't waste your time understanding a lot about the pelvic movement because yeah, uh it's, it's, it's, it does nothing and but the the vision will hip pain, patient with hip arthritis, patient with uh spinal pelvic problem. Uh like the patient with ankylosing spondylitis or severe severe uh um uh ankylosis in the back or, and uh or the spondylitis, they suffer a lot with this movement and this makes their gait abnormal gait because there is no coordinated, simple transition of pelvis movement. But you need to understand that is moving in the three lane. So it moves from side to side by the abductors about seven degree, it moves to front and back about four degree and it rotates about 10 degrees on both sides gives you this normal range of movement, which is like an itching if we come to come to speak about the kinematics of the gates. So when we speak about kinematics, we speak about the movement, we don't speak about the force that's causing this movement. So all of us understand that the way it stands face is the longer face, about 60% of the gate is its way face, about 40 percent uh stands, face starts with a heel strike. Stands face means any part of your foot is touching the go. Now we speak about the right foot, which is, is in a blue color heel strike the loading response when you put all your foot down, then from this medicine, when you stand straight and, and steady on your foot, then you start to, to off when you move body moves forward and they start as we agree, um flexion in the, in the, in the, in the ankle joint, uh bladder flexion in the ankle joint and uh flexion, the MTB joint then for this to brewing, then two off and from two off to middle swing and from middle swing to 10 minutes swing before you hit the ground again with another heat strike. And this is a whole gate cycle which is stands and swing face. Yeah. Yeah. All of us and all of you know that when we come to kine kinetics of the gait, we speak about the forces moving the gait and how you do this kinematics. And we understand that we start with he, when you heal the go reaction force is coming from behind your ankle in front of your knee. And B by that, it's bluntly flexing the ankle passively and extending the knee passively. And that's why in this stage, your tibialis anterior is working extend eccentrically. So it's working eccentrically just to stop your foot from slabbing in the ground. So the ground action forces behind your ankle trying to move your foot in a blunt of flexion and by eccentric contraction of the tibia is anterior. This means this movement is smooth and easily transition without slabbing. That's why the patient with foot drop or has no tibia. Anterior function walks with a slapping gait every time he touched the ground by the hill, the the eccentric contraction of posterior uh anterior is lost. So the patient is dyle the ground from this, the body starts to move, which is the loading force, which is normal, but it will by the inertia. This is the second loaf of, of um neotine. So the body moves by your inertia. So the loading phase happen during the loading phase. As you can see, this is, this is a ground reaction force line was before behind and behind the ankle in front of the knee. Now, with the ring force, it become a across the ankle and behind the knee, it is a flexing force. And because a flexing force, the quadriceps muscle act eccentrically again, just to stop you from over flexion. Once you go to this is you're progressing from this stage to this stage. This is the way that so starts to act and stopping the progression of flexion of your um uh your gait of your the knee flexion until you go to the mid stance by the mid stands, you see the ground reaction force become going in front of the, uh and throw the ankle in front of the knee, then across the front of the ankle. So it's now a dorsiflex in the ankle. And because it's dorsiflex in the ankle, you start to off and by toing off this time when the tricep sur is acting, is acting as uh eccentric contraction from this stage, you start to get your foot off the ground and by getting the foot off the ground, this is where the hamstring start to act. And at the same time, it concentrically and quadriceps eccentrically until you clear your foot. Then from this stage, you go to the terminal phase when your foot, it knee is straight and your, the line of uh line of your weight is straight until you go to the uh uh the the next he is right. This kinetics, you can find it everywhere. It's not a difficult one you need. Just to understand, I never, I never um uh uh II always understand it. I never go to it. Like I don't, don't, don't keep it by heart. I just understand it then how can you assay the gait? So there is formal way to assist the gait. So basically history, physical examination function is scoring uh videoing the patient which um what we call the the gait gait lab or gait analysis, gait lab analysis. And in the gait lab, you, you video the patient, you for the patient from all the sides. You you bought some uh sensors over the muscle, some sensors over the joints. And this is gives you an idea about the kinetics and kinematics and you do an image for the muscle to see how much action is happening, how electric action happening inside the muscle. And the end you do video biography, we barography which is you measure the pressure of the foot over the ground. You have some beds, some mets and beds, mets and beds of which this is the pressure where you load your foot and how much you load it. So the right on the right side, you see you see the physical examination chart of older ha hospital in Liverpool. So taking history from the patient physical examination through a a an a specific a specialized chart like that function. It it includes function scoring when you go to the gate lab where you video the patient bought some sensors over the muscle to see the kinematics or the movement. And ki and I'm sorry, over the joint to see the kinematics and over the muscle to see the kinetics do mg of the muscle to to see the electric uh um changes inside the muscle and in the bi bi where you test the pressure points of the foot and where you pressurize the foot. And this is um the gait analysis lab in uh Alder Hill Liverpool, you see cameras from all the sites the the girl has sensors over the the joints to show what movement is happening, which is a kinematics, kinematics and I'm sorry, a kinematics and sensors over the muscle to take an EMG and show what is what is the kinetics of this movement. And on the floor, this met has uh a bit biography where it this is the pressure points of the foot where where this girl pressurized her foot. So if we, this is a normal gait, I hope you get a brief idea about it. You understand what's normal gait? You understand what's the pre requests is for normal git, you understand how you get to be efficient. You understand the ground reaction force stia rotation, um uh coupling flexion, extension, uh knee flexion, uh extension or coupling. Now we'll go to the abnormal gait and easily to differentiate an abnormal gait in the Children. It may be habitual which is like the two walker or toing. It could be from bein or trauma like anal gait. It could be a additional profile problem like the into the pathological inter gait. It could be a joint pathology like the stiff gait. And it could be a neuromuscular disorder like the crouch gait, the stiffening gait and the spastic gait. And it could be a brain injury like the ataxic gait and it could be neuropathic like the highest gait. I will show you an example of every one of them just a quick video to show to understand the difference between different types of gait in the MYOB gait. So this girl will be walking with an antalgic and an antalgic gait refers to a painful limp and basically what she's doing, she tried to on the side extent weight bearing. So specific posturing she walking with short distance face on the painful side, not to lose the painful limb. And this what gives you the the the the picture of Antalgia. This uh kid as, as a lot of kids we see in the pediatric clinic is walking with two walking gait. And then on the right side, you will see have a look on this kid. What this kid is doing is walking with inter gait. But this is a physiological indo incompatible on both sides, the physiological inter in comparable on both sides because uh he has an uh an anti ex ee excess anti version of the femur. This is totally different from the girl on the left. As you see the left of the, the the girl on the left has very tightness and contraction of the AUC muscle. That's why she walking with pathological and inter gait. If you see this patient walking, you can see he barely move the joints, he walk with very, very stiff gait. This because he has a diplegia, spastic diplegia or a stiff gait. If you have a look on this girl, when she walks So she basically have very weakness of the muscle, of, of her muscles of the, of the lower limb. She have weakness of the flexor, weakness of the extensor. And she walks. That's why no, none of her joints are stable and this is the crowd she gave. Then if you see the gentleman walking, you see that there is nearly no flexion and this is basically a step gait. This guy again, see how is he walking? So all, all his muscles are spastic. That's why he walk in a spastic ability gate. Look at, at, at the gate of this girl, what this girl is doing. So you can see that this girl basically, uh that this girl doesn't, doesn't uh clear the right side because she just lean on one side because she has a hemiplegic ate. If you have a look at this guy like a drunk gate, which is a taxi gate because of a brain problem. And if you see this nice kit, he's just cleaning his foot by flexing the head and knee. Uh because he have a foot drop or a high gait. And if you look on this guy, you can see he walking was basically waddling it. He has no support from the trunk muscle because he is myopathic. Um I hope this part of the direction is ok. We um 40 minutes. So we're nearly on time. Um I'll go now to speak about the foot and ankle examination kindly if you have any question about the gait before I carry on. Mhm. Any question about the G guys, I'll be so grateful if you all understand this. That's a, that's a great success. I'll be a winner. Ok. Is it K Hazam? Yeah, it's, it's ok. Right. Is it clear or not? Uh, it's ok but uh uh you know that it, it, it, it, it's not an easy one. So I think you anyway, the video will be there and uh yeah, II hope it will be, it will be fine. OK. We'll go for since you. Yeah, this maybe yeah. Difference between in town and uh uh a good question. Very good question. So inter wing is. So uh inter means it's just a rotational deformity. It's just a problem with the rotational profile of the limb. There is no action for the muscle. So basically with excess febrile and diversion with excess tibia, internal rotation, you the ba patient will be walking with inter gait very smoothly, scissoring gait. It means the patient has some spastic uh pathology with the abductors. So the patient is walking this way. So this is to smooth movement because a rotational deformity of the limb with no muscle problem, scissoring gait. This mean the patient has some problem with the doctors. So the doctor is in a spastic position. So the doctors is working uncoordinated movement. So the patient is working in this way. That's why he's scissoring. I think uh Kartik, this is clear, so easy way both of them in to the first one in into into is into because of a rotational deformity of the limb scissoring is because problem was abductor, I mean spastic abductors. No worries. Ok. Mm. So going back to the foot and ankle examination. So uh we start with the history and from the history, you can spot a lot of the diagnosis. So the site of your pain is very, very important. So if the patient come to say I have a heel pain and we have the commonest diagnosis of plantar fasciitis. If the pain of the patient is in the midfoot and is just vague and burning, burning pain and paces, we can uh um um suspect he have a tarsalis syndrome. If the problem is in the forefoot, could be um hallux valgus could be a clo to could be a Morton's neuroma could be a Fry's could be a tariff too. If the pain has started after an ankle vein, it may be an osteochondral lesion or OCD. If the pain aggravates on dorsiflexion, it's an anterior Benjamin or tibiotalar inm. And if the patient, if pain is at risk, so mostly it's not mechanical. The problem is inflammatory and this is happens with a sinusitis. If the b if the patient with the vein have some instability, it be may be a chronic later ligament injury. If the patient has a deformity, you easily can spot, the difference between bis SCS and bis planus. And if the patient has complaining of catching sensation in the joint, could be a for uh um uh a loose body could be an OCD. It could be some per tendon subluxation, which is a very, very subtle thing and very, very easily missed if the vision has burning pain and numbers in the toes and he feel like he walk on a stone. This is a characteristic complaint of a MS neuroma patient. If the patient says to you, my great toe looks triggers and have um post medial ankle pain. This patient mostly FHL symptoms. If the foot is rigid and has a recurrent brain, you may think about TSA correlation, especially if, if we speak about adolescent or injury. If you ha if the patient has a difficulty wearing, that shows you this is the time you need to look at the toes with, with, with difficulty wearing shoes. It's mostly a tool problem with every foot and ankle patient. You need to take a proper history. The the main medical history of concern for us is diabetes, rheumatoid arthritis. And how, what type of management, what type of drugs and is it controlled or not? And neurological disease is definitely for the clawing and, and the kid problem. You have to understand uh to ask about the social history, especially the smoking, the smoking makes the risk ma makes the risk of infection and nonunion. In foot and ankle surgeries. The double, which is a, is, is, is, is, is, is a very, very, um, uh, worrying and a very, very risky. You have to see if the patient have a social support because basically after foot and ankle surgery, they will be, um, have protected weight bearing or a difficulty with weight bearing and they definitely need some, some support. After the surgery, you have to have an, an idea about the family history because the Helix ques run in families, especially in females. So it comes from mom or or aunt to uh to the girl. Then when you examine, we will go, I will, I will show you my my my system examination in my clinic. So I start with the patient standing. I have a look firstly around the patient. So I have a look in patient. If the patient using any aids, if the patient using any uh what, what is the shape of the shoes of the patient? You, you spot a lot from this. The patient with Heu Valgus, you will see the foot, the foot, the shoes has a prominence on the medial side and the shape of the toolbox is not normal. Same. The patient which you have uh abnormal loading of the foot. You will see some specific or types of wear and tear in the shoes and in the, in, in, in the, in, in the sole of the shoes, I'll have a look if the patient have any orthotic, I get the insults out of the shoes and have a look on them because they give me an idea. Uh If I see like an arch support shoes, you understand, uh r support insult so that the patient has some problem with the midfoot. If I have a rocker bottom, uh insoles, this means the patient, a rocker bottom shoes. It means the patient have a problem with ankle arthritis, patient, if have a more extension orthotics, I understand that this patient may have a headache surgery. Uh then I look generally into the limb alignment. So how the patient stands in front of me is his shoulders leveled. Uh is his pelvis uh uh centered or obliged. And if there's obligated to which side, if he has a leg discrepancy, if he has any aberrant deformity of the hips, knees like flexion deformity, virus vs deformity of the knees, or he has any clear deformity of the ankle, uh and foot. Then I asked the patient to turn 90 degrees to the side, then 90 degrees to the to to behind. So actually, I do the side before behind. I should have um uh spotted that from the side. I look into uh the arch of the foot. So um I have a look on, as you see in this picture is the arch of the foot is, is, is, is, is a low arch or a high arch. Is the patient is in CVA is the patient is in Planus. And uh then from the back, I have a look on the patient and ensure that the patient have the normal physiological uh meaning five degrees of vuls, ask the patient to tiptoe and see if this vuls goes into virus. Which means that subtalar joint is sub. Then from the back, I have a look. Um on the two mini two side means I can see more than 1.5 toes uh from the back. This mean this foot forefoot is abducted and this is um one of the pathologies was basically I can spot easily as you see here, any hagland deformity or a bursitis or problems, I can easily spot as you see uh different in the muscle circumference and wasting of the calf muscles. And I can see definitely if the vision has any uh varicose veins. But from the front, I have a look in the foot, I have a look on any deformity of the fore foot, any uh abnormal, any scarring, any abnormal tissues, any abnormal swelling. Commonly to see a a adult gangl in here around this area. Commonly to see a hallux valgus, common to see a hammer too, to see a mallet toe, uh to see any I's playing less toes to see abate. Um So easy to spot any of this while the patient is standing. I asked them to walk to the door and back to me slowly and normal. And I can easily spot what we spoke about in the first half of the lecture about the gait analysis. And if the patient have a specific gait, it has, has he have, um, has he has uh, no r three rockers, ankle, 4 ft ankle, midfoot and forefoot or ankle or heel, ankle and 4 ft uh rockers or not. And how he normally walks is he antalgic has an antalgic gate on one side means it's painful for him. Um And from the git, I can get a lot. Then while he's standing there, I do the common block test which you see here and to understand the idea of common block test, the normal tripod of the foot as, as I have shown you have the weight bearing goes through the foot. So you do your heel, you load the lateral border of your foot, then you load the, the, the head of first and this troo has to be continuously in normal. Um, uh, relation. That's why the problem with the KVAS patient is this, uh, uh this part of the Ribo which is the first tray is dropped down and because it's dropped down for the whole thing to be walking normal, the patient get the heat into virus. So you walk on a troo, which is how the lo the weight is loaded over the foot from the hill later border of the foot to the head of first meal. And for this for you to walk, you have this tripod to be at the same level. If one of this tripod has changed the whole time, it will change accordingly. So with the CVAs, your first tray has dropped. So what's happening for the other troo, the only option is to move this way to get the 33 points of the tri in the same level. And that's why the CAVA has a virus element. So virus hind foot, uh uh Cava or high R foot and at the same time abduction of the foot. So because of this, the common idea of common block test is to raise the first ray again to normal is rather than the side. But this way it load this normal and see how, how the foot will correct if the whole tripod corrects. This means the forefoot was a problem. If the hind, if the whole thing hasn't correct, this means the hind foot was a problem. Again, tribe of the foot heal later, border and first tray or or first head. If the, the CVAs is 4 ft driven, the problem starts in the 4 ft, the the first tray will be dropped. And because it's dropped, the only way for the tribal to be at the same level is to move this way and make the foot into, into virus. So what I'm testing, I bought something underneath this tr trying to get up, allowing the forefoot to drop and see if the, if the first three drops goes to the normal, how will be the situation. And as you can see on this side, once you correct that, that once you, you drop the first tray, you give it, give it a space from the ground, the whole tribe would correct. So this is the picture of the troo if the 4 ft, if the bottom is 4 ft driven, once you load all the site, the full whole foot position will be normal. And this, you know that uh your KVAS is coming from the 4 ft pathology. The other way is the reverse uh common block test. And we do this for bis Planus. It is not that common, but you can do the same, the same with bis Planus. Bis. The, the arch is the arch is flat and for the Tribal to maintain the arch is flat, that's why this is raised up. The only way is for whole tri is to go this way. So if I raise the first ray, which is was uh uh uh if II lo the first ray, the whole tribal would correct. So this is a Coleman block test and this is the reverse Goldman block test. Jo anyone um don't understand that. Um Yeah, it's clear you can carry on. It's clear. Yeah. Yeah. Yeah. So once you put your ba your patient on the couch, you look in your normal foot attitude, you have a look in the sole of the foot. And this will give you a lot of ideas because it shows it makes a bit barography f normally for you, it shows you where is the area of callosity, where is the area of overloading? And you once, once you correct the hind foot, you can see easily what is the deformity in the forefoot. This is the idea of the tripod again. So as you see on the right side, so this patient has a bis planus. So his foot, his heel was in valgus. So the deformity in his foot actually imagine with me, this is the troo, he went into vuls. So what will happen for the whole for foot to get the troo back is to move into submission? That's why when you use correct the heel vuls, once you correct this, basically, you can see the he the 4 ft subin easily and the other way in the cavus. So in the cavus, this first ray is dropped. So the whole foot went into ation. And once you correct the heat virus, you can see the corn of the whole foot of the forefoot. So other than your understanding, if you have a look on a flat foot patient, you feel that he is in a heel vuls and pronation. But this is not actually the reality because to understand the reality of the 4 ft position, you have to get the heel back under, under the tibia. And then at that time, you will realize that the forefoot in the, in the base planus or flat foot is actually subin not pronated other way around in the cavus patient in the cavus moves with foot seems to be subin. But actually when you correct the heel virus, the whole forefoot will be pronating, then you have a feel. So you feel for any tenderness, for any bony prominence, you feel for any swelling, Uh then you do a drug test and drugs test is actually testing that uh when this action of the bla bladder fascia, we explained before blatter fascia is moved, is, is attached from the posterior prostate here along the central band and the two media lateral bands across the MTB to the um to the bladder blade of the, of the toe. That's why when you, when you uh dole the toe at the MTB joint, you bone on the fascia and this, if the fascia is intact, the will be maintained or should be be before I'm sorry. So Jack's test is basically to test the integrity of the blann, the fascia. And once you do the windless action, when you dorsiflex, the to the whole blatter fascia will be in, in tension and this that the time the blader uh the the, the long and will be formed. So as you see, vision is flat, once you do dorsiflexion of the toe by windless effect across the MTB joint blatter fascia will will go in tension and that's where the arch will be formed. Then you do the Moors Rick. If you're suspecting uh tenderness in second or third will be space because of a Mortons in neuroma. And basically, as you can see, you're just holding the lateral rays, you're holding the media rays and you just move them against each other. And if this is a neuroma there, you will hear a click, what we call mos click and you can feel the achilles and you can feel the uh plantar fascia from the achilles. You can differentiate if there is an insertion, noninsertion, adenopathy. And if there is a highland deformity, if there is erythro Calcaneal um problem or bursa or not, when you have to know there are two questions. So the first question, the difference between legs, discrepancy gate and FBG gate. It's a very good question. Who asked you this question? Uh OK. So to understand the difference between um between leg length, discrepancy or short limb gait, you a you ask about short limb, it doesn't mean discrepancy, gait. The gait is short limb gait and the difference with limb gait. Come with me. What the trend bag is basically, I have to have the, the the free body diagram of the hip to understand this. But imagine with me, you have your pelvis, your two abductors on both sides and your foot on the ground. OK. When you, this is the right side, this is the left side. This is the abductors. This is the pelvis in the middle imagining with me. When you get the left foot of the ground, what normally happens? The pelvis will go up on the left side because there is no support. Yeah, that the time when the abductors on the right side will bow the pelvis back and make your pelvis balance it. If you have a problem with these abductors, what will happen on the right side? If your abductors on the right side, myopathic uh uh weak uh injured has a severe gluteal nerve injury, whatever the cause abductors are not working. So every time you get your left foot off the ground, the pelvis will drop on the left. And for you to correct this, you have to move all your trunk to the right. Because if you remember the free body diagram of the hip, the center of the hip is the center of rotation. Abductors with liver arm on one side and weight of the body and liver arm for the weight of the body on the other side. And this this this forces should be uh in equilibrium for the pelvis and hip to maintain a steady in place if the abductors are weak. So the only way for you to manage this is to move all your body toward the hip. So shorten, shorten the lever arm of the body weight and this is gives the abductor less function to do. And you try to minimize the function, the abductor or the force the abductor needs to generate because your abductors are weak. Again, two abductors maintaining the Bavis in place. If the abductor is normal, when you get the left foot off the ground, the right abductors will be contracting. So getting your Bavis to straight to be to be straight. Again, if our vectors are weak, you try to lean your body toward the the the problematic or pathological side to minimize or shorten the moment arm of the body weight, which gives eno at least function for the abductor to do see least four for the abductor to do. So you help your weak abductors. So the patient, when the patient walks, you see the patient pelvis drops on the left and shoulder, drop on the right, maybe drop on the left because no support and then should the drop on the right? Because you lean by your body toward the pathological site just to shorten the liver arm of the body weight to give to us less force to less. Um this work for the with the trundling be gait, you have this dog on one side and the shoulder lead to the other side, which is different completely from a short limb. On a short limb, your short limb is the left limb, OK. When you walk a short limb on the left, every time you put your foot on the ground, pelvis and shoulder drop on one side. If you have a look on the patient from the back, the patient will short limb, the gait will be wa will be walking with shoulder and, and then it gobbing on one side or while the patient with abductal deficiency or gland be gait will be walking with this gobbing on one side and shoulder throbbing on the other side. If your pathology, if your short limb is the left limb, you will be walking with shoulder is throbbing on the left. If you have a pathology on the right side, abductors, you'll be walking with the Elvis growing on the left and shoulder leaning to it. I hope. Listen. Yeah. Sure. Uh Another question I is it Jack uh left off test for uh for flexible bius the same principles as reverse Coleman common test. No. So reverse common is different. So reverse common for every and each foot driven 4 ft driven uh base planus will be correcting test can be, can be negative if, if the foot is a midfoot is rigid. So the f the ar cannot be recreated if the bladder fascia is ruptured. If the patient has a first MTV pathology, a lot of pathology, you need to understand the mechanisms behind every test and easily you can do it. This is a tribute. This means a four driven means that the first day is is do like it. So for the whole tribute to work to do the action, the whole tribal needs to go this way. So when you, you raise this from the ground, so no looting of the first ray, the whole bo will be correcting. This is the reverse Co Jacks test your fascia, your blatter fascia is going from the Tachia to prostate all the way to the first MTB. Then it goes to insert into the blan plate every time you push your toe in dorsiflexion, you tension the blatter fascia and the blan fascia. If tension means it shortens and the only way to shorten is to create the jack test would be reverse. Common will be positive if the problem of of the base that is coming from the hind foot or jus test will be positive in a lot of conditions stiff midfoot, like severe arthritis. Uh So arch cannot be recreated, plantar fascia, pathology. First, MTB pathology or heart surgery does l ruptures a lot of a lot of pathologies. OK. Yeah. Can you repeat the tripod again? So try both as you, as you remember how the foot, how the foot gets the load on? He move to the latter border? Then the first, then the ball of the first three or ball of the first metarsal. OK. This tribal should be on the ground all the time at the same level. OK. What's happened with the cava the 4 ft? The first, the the arch, the arches, high arches, the harsh is exaggerated. Yes. Means that the 4 ft mean that the first tray has dropped more. Yeah, it's like that how we can get this tri to act to be normal. Again, you move the tr hole, the troo is there. So here goes into virus and 4 ft goes into coronation. Ok. Tribal back. This is the normal tribal. What's happened with the, with the best plan or flat foot? The first tray is dorsiflex it. So the arch is low. Yes, for this arch is low to be corrected for this. This um try to go normal. The whole thing has to go in vuls. So Vuls um high foot and sobin of the forefoot. What you do in what you do in a common block, what you do in common block, you load this tribe, you correct this tribe, you're free. What you actually do? You free the first ray. So free. First ray is not loaded, you just normally load the other parts of the troo. So if the problem is just from the forefoot, which you do, you unloading with the, with the common block, the whole tri will correct. This gives you an idea that the problem was of the was for in the forefoot of the first ray. And once you get it off the ground by putting something underneath the border of the foot, the whole thing is correct. First best gave us the whole thing to correct has to go this way to B to be in the same ground and the other way around. Ok. If we go to the neurovascular examination, we aim to finish on time. If you go to the neurovascular examination, you have to do a proper neurovascular examination because big, big part of our practice is diabetic foot or, or neuropathic foot. You have for neurovascular examination to ask if a normal patient, you ask just about the spine. Do you have back pain? Do you have any uh neuropathy or weakness? If not ignore the spine and go and e examine the briefly, you examine the briefly for light touch and be break and you test for um you test for if you need to test for any sensory deficit, use a 10 g filament what we call sensor when it's time, um when it's time, um filaments, it 10 g is available in every foot and anchor clinic. And you, the idea of this is 10 g in, in, in, in weight when you abortion certain point, if the patient doesn't feel it until you bend the, the the filament, this means that this patient has a neuropathy and we both it in to great. Normally, if you give it to a normal person, once you touch it with thin gram, the patient will feel it if you touch it with 10 g and patient doesn't feel means you have some degree of neuropathy. You start bush, bush bush and the the famine will be bending, bending, bending bending. And this gives you an idea how much neuropathy does this patient have and thing gram. This is a specific you need to, to you need to remember it. So if we come to the distribution, we understand that the sinus is covering up to the no the is coming in the the the first space which is covered by the perineal and the lateral bordering by. Then if you go from the, from underneath, you have this area, that area number six is from behind by the posterior tibial, from the outer side, by the shoulder, from inner side by the cephalus, then the media bladder covering the media 3.5 toes and the lateral blan from the posterior tibial uh or TNF is covering the lateral uh 1.5 toes, uh then the movement. So movement you have been a foot, an examination, every patient has to have a bit score. You need to see if the patient has any um eous hyperlaxity or not. Bit score is a score from nine. I'm sure all of you know it, if the patient has 5/9 or more, this means the patient is hyper lax and this is this score is uh this score is invalid in the in the kids because the kids is hyper lax. So don't use it in the kids is a very going in the exam. You test the active and range of motion. If every joint finish to the ankle joint. And once we, while you're testing the ankle joint, you do a squeezing test and the squeezing test. Basically, you understand that the tibia is behind the fibula and you put your hand over the fibula and the, the four, the fi the thumb over the fibula and the four fingers over the tibia. And you start to squeeze to assist the synthes moses. If the patient has any vein in the synthes moses, this gives you an idea that synthes moses uh could be injured. Then anterior and Benjamin test, as you can see on this side, you ask the patient to keep the toes against the wall and to bend the knee. Then you ask the patient to move back and bend the knee. And this gives you an idea how much the patient can move, can dorsiflex the ankle actively. And this gives you an if the patient is in pain in this position means there is some tibiotalar impingement anteriorly. Then you ask the patient to move the subtalar and to move the subtalar, he has to move the foot in and out to do a so by nature, not inversion, inversion, but ask the patient to move up and down. This is the ankle, ask the patient to move in and out. This is the subtalar and for you to test the subtalar you have, as you see on this right side again, you have to stop the ankle from moving and just move the hind foot because if you move the hind foot without stopping the ankle, the movement of subin pronation has some contribution from the ankle. So to test the subtalar specifically, you have to stop the ankle by your fingers or by hand or whatever. And t the hind foot, how much the calcia moves over the talus, the to go to the shoulder joint and from the shoulder joint and the rest frank joint. And then, um you, you ask the patient, you, you stress, you stress the forefoot in abduction, abduction to stress the shoulder joints. Then you test for achilles tightness. As you see here to ask the patient, you, you try to see how much the vision can basically dorsiflex in knee extension and then ask the vision to bend the knee and see if the vision dorsiflex is more with bending the knee. This means itself test positive, but this means that the, the, the gastroc is tight. And once you flex the knee, you get the gastro out of the equation. And that's so the tender achilles and soles are ok. But if you both the patient knee extension, dorsiflexion is limited. And when you bend the knee, it is still limited means the whole complex is contracted and this is going negative. Then uh don't say se called positive to negative because it's differently interpreted everywhere. Just say that this patient can basically dorsiflex, a knee extension up to this and a knee flexion up to this and anyone who read it, he knows that if the knee extension, if the dorsiflexion, basic dorsiflexion in knee extension is less than knee flexion, this means the gastroc is contracted and the tender and are ok. If the patient has limited do basic dorsiflexion in both knee extension and deflexion means the whole complex is contracted and this makes a huge difference if you plan to do an operation. So if the patient have a, a limited basic dorsiflexion in both extension deflexion, there is no point to do a gastric release. This is going to do a lengthening of the achilles because the whole cold complex is contracted. But if the patient has limited dorsiflexion in knee extension, and once you flex the dose, if ve dorsiflexion improves, this means the gastroc is short or contracted and this is the time you do a gastro proximal gastroc release. Then if you have any deformity, you have to check where the deformity comes from. You can, you may not a be able to do this by inspection only. You need to check if, if the, the, the deformity you have is flexible or not. You have, you have to check if the deformity you do is correctable or not. And then with the hallux or arthritis of the first MTB, you can do a grinding test to confirm if the patient has a hix or not, then you earlier your examination by stability and testing the stability you test in anterior drawer and virus inversion. And we agreed last time anterior drawer to do it with testing in the anterior to the fibrillar ligament with both the ankle and blan flexion. Patient knee is bended to relax it like a stroke in bla infection. And I do just the anterior drawer and if I want to test the posterior Teri friar, I just do the same. But inds flexion, Hawaiian virus inversion, we testing the calm fibrillar. So both the the ankle and neutral knee is bended and then you do virus inversion, then you finish all this by twisting the tendon. You need to test tibialis anterior, which is means you're twisting the ankle and the the foot while the ankle is in uh blunt flexion and trying to invert tibialis posterior ankle and dorsiflexion and trying to invert very near as long as ankle is in um blunt flexion and trying to invert. Uh and I'm sorry, dorsiflexion, trying to invert be previous ankle is in blunt affection and trying to evert. This is how to test the four tendons. If you cannot see any problem, you have to think about something sudden it's not clear in your exam, clinical examination, which should be as the osteoarthritis instability or he r then have a look in the shoes as we agreed from the start, remove the insoles describe, is it accommodative or corrective? Uh It's there is he which if there is our support. If there is uh Morton's extension or whatever, have a look on the sole of the shoes and ensure if this is normal wear, batter or this area is more warmer than the others. And if there is some buildup which has been brought in, if there is custom made shoes or not have a look on the hand, if you suspecting the vision has a rheumatoid arthritis or hereditary since, since, since motor neuro uh neuropathy um or charco tooth and have a look on the spine. If the patient has back pain or any history of a spine problem, especially in young adults, you need to exclude any spinal dysraphism, spina bifida or any spinal surgery. Uh Are we OK to this with bispina? It will take good 15 minutes guys, write me with me in the chat so we can keep the bis for the next time. If you are happy, we can go ahead guys. Sorry, go ahead. Ok. OK. Good. So if we speak about best plans, I'll be try to be quick. So you understand this plan is actually a best plan of Agus. OK. So you can have CVAs without it um virus, but you cannot have a plan uh uh a plant without fungus. So this plant is this plan of vs foot. And as you can see, it's, it's three component is without arch in the mid foot. It's valgus in the hill and it is sobin nation of the forefoot and this is comes to the tribe of the point we explained before. So what you will find in the history in a flat foot patient, the patient will be coming to uh complain from a lateral heel pain. And this is very common complaint. And to understand this, you have to look on this, this picture as as you can see because the heat is in vuls, the patient has will have some subfibular impingement here. And that's why the patient will be complaining of pain on the lateral side. If the patient complain from being on the media side, it either this patient has at correlation media or because of the stretch of the media destruction including the deltoid ligament. Ok. So the patient will be complaining from lateral heel pain because of subfibular impingement or medial hip, medial uh side pain because of stage of medial structure from the history, you cannot spot the information as a child. So the commonest cause is correlation and you have to check that unless it is flexible. And if an adult, you have to suspect seriously that this patient have a TPO insufficiency. Before anything else from the medical history, you need to know if the patient is diabetic and neuropathic or not. If the patient has a rheumatoid arthritis means all the soft tissue structures are weak and you need to spot if the patient has a hyper mobility and this is is idiopathic for him. The on examination, you definitely has to have a lock on the shoes. You will see that the the medial side of the shoes is worn more than the lateral side because the patient walking in vuls and losing the medial side of the foot more than the lateral. Uh you have to open the gate and easily you can spot that the patient because what is due with the blunt of flexion and inversion is a tibialis posterior. And if the tbis booster is weak, you will find that this patient has a reduced blunter flexion during swelling face, you will see that the patient has a hind foot, valgus and again collapsed, medial arch and a 4 ft abduction which you spot from the back way while looking in the patient from behind as a two mini two sign, which is means 1.5 toe is seen from behind. Uh You ask this patient to do a double hair, eyes and double hair eyes. You need to understand you're just looking into the sub joint to see if it's walking mo moving or not. So you compare normally you have five de the physiological five degree of vs on stents and when you walk or when you stand it toe or you double he r that your normal he if the, if the subtalar is ST the B Calcii will go into virus. If this happens, this means the subtalar joint is working and why was double heel rise because even if he has a tibial in tibia is insufficiency on one side, the other side will be helping the body to go on tiptoe. And once it goes in tip toe, if the, if the subtalar is sub, both heels will go into virus. So you're doing a double he R just to ensure that the subtalar joint is working and sub um the single hiri test is basically to test the tibialis posterior tendon and you cannot test it once because sometimes the tibialis posterior is not, is not um uh absent or ruptured, but it actually weak. And to, to get the, the muscle, the weak muscle to explain itself, you have to repeat this, he at least five times or ask the patient to go in a tiptoe and stay there for um like 2030 seconds because he can do a single hair rises quickly and we're done. And you say, oh no, no. After that was the, the, the patient is doing uh tip the doing a hair R normally. But to spot a week muscle, either to ask him to do a hair R or tip to for a while like 2030 seconds or ask him to repeat the single hair R for a week to be on his posterior to express itself. Then you can examine the tibia booster itself. As we explain again, ask the patient to invest in blunt affliction, then assistive subtalar and ankle movement is it fixed or flexible assist for gastroc tightness? And I will explain you why gastroc tightness or tender or achilles tightness. Why you must comment on CIS in every flat foot patient because the achilles is normally a vuls in force. So the achilles will be always tight in bla and in this planus. So and this is will be part of your correction. If you blad a surgical correction for aby planus, you do ajax's test again to ensure that your midfoot is fixable. And the blann fascia is intact. As we explained, you have to have a a neurovascular thorough neurovascular examination to ensure that you don't have any area of neuropathy. Then we speak about very important point, which is the both of anatomy and pathophysiology. So, the both anatomy is we understand from the anatomy is that the calcaneum is not directly under the tibia. And the, the, as you can see here, the subtalar axis is just lateral to the mid mid uh line of the tibia. Number two, you have three arches. We agreed before that the, the, the the medial arch, the key bone, the keystone bone here is the navicular is maintained in place because of static and dynamic stabilizer. The dynamic stabilizer of the tibia is posterior and the bladder fascia and the static stabilizer is a sprain ligament and the interlocking between tarsal bones, lateral arch. It depends on the shape and uh the shape of the uh lateral ray is the 4th and 5th ray and is maintained by the lateral ligaments. Then the transverse arch is maintained by Peroneus longus and uh interosseous ligaments. The boss of physiology is you understand that this as a normal adult, if he doesn't have a bony problem, burning problem, oral c correlation, it happens because of tibia failure for any reason. And with tibia booster failure, we agreed from last time that there is groups of muscle working in, in, in, in uh in um in accordance or in coordination. Tia posterior with tia longus uh longest. Once the t posterior fail, the be brevis takes predominance. And that's why there is the 4 ft, the hind foot goes into valgus, the mid foot goes into uh uh plan flexion or um I'm sorry, do flexion or flat arch. And the forefoot goes into abduction. If we go and remember the tia booster function is to blunt reflex, the ankle invert the hind foot and abduct the forefoot. When we lost this, the hi the the the the the ankle is easily in going in dorsiflexion. The mid foot is flat arch, the hind foot is in vuls and the fore foot is in abduction because the counteracting muscle, which is the be brevis is red, dominating over the feeding over the weight tibia posterior. Again, as we understand because the subtalar axis is just lateral to the midline of the tibia. That's why the achilles tendon in its normal situation is a vuls in force. It's aimed to go this into vuls and when the patient is in vuls or base planus, that the the achilles goes to be short and tight and this is maintaining the position of the base planus. That's why you have to lens in the achilles before you do anything for your flat foot. At the end stage. A lot of vuls, heel, heel vuls, a lot of stay on the media structure, deltoid start to be insufficient and this gets you to grade four bi or booster booster to be tender insufficiency. And this is when you have to do something for the ankle, not only the hind foot and forefoot, uh what the etiology of viral or flat foot is either congenital like a vertical talus like a Tulsa coalition, which is very, very common in Children spina bi because of weakness of the muscles and CB acquired. The commonest cause in adult is is posterior insufficiency or rheumatoid differently because it deformed the joints ball you because of weakness of the muscle degenerative like arthritis, especially in hi and midfoot or could be iro because of failure of correction. Uh It's very common to happen with failure of correction of clubfoot. If you do a ab paucity technique or if you do overcorrection, you will end by a occurring foot, which is a form of flat foot. It could be physiological. Yes, it's uh most of the kids in, in the early year of life, first year of life, they abnormally physiologically like that because they have flat foot because of um a lot of fat underneath the fat underneath the uh the, the arch. It's actually not the arch itself. It's, it's flattened, but there's a lot of fat underneath it. That's why if you have a look in your kid, which is less than a year, you will find most of them are flatfoot physiologically without any problem, could be flexible because of ligament ligament deficiency. The commonest uh um example for this is Ehler Down syndrome. Uh it could be a normal variant. Yes. If you look in a lot of vision, you found them flat without any pathology together with serious function. Joints are, but they are physiologically flat. As I told you, 40% of the patient born with flat feet and 10% of the patient are flat at 10 years. How to assist an x-ray for a flat foot. You have to look on a weight bearing x-ray or what we call the fourth series. So fourth series is eb lateral oblique of a foot while patient is standing. Why standing? Because you need to see the actual situation of the joints in your normal day when they are looted. The first thing you look from the front, back to front or front to back, whatever you want, you have to look firstly on the forefoot abduction and you cannot spot the forefoot abduction by looking into the uh T UT cover. Normally, this navicular, I'm sorry, t navicular cover. Normally this navicular should be here. So the line, the axis of the talar should be going with the axis of navicular and forest tray. But as you see, the axis of the first three and the navicular is there and the axis of the talus is there and there is all of this uncovers about 40 degrees or we can calculate this other other than this angle, calculate how much of the, the navicular, the talus is not covered by the navicular. And as you can see, it's about 50 to 60% uncoverage. This means severe 4 ft abduction, abduction. So first thing to look at is the forefoot abduction. And to look at the forefoot abduction, either you can create the angle between longitudinal axis of the talus and the line of the first ray was the navicular or to calculate it with how much of the talar head is not covered by navicular. And if this uh uncoverage is more than 50 15% we speaks about significant 4 ft abduction. After this, you go behind, this is the midfoot, you go to the hind foot and the hind foot from the eb you can spot what we call the kite angle. So if you see it's like if you complete these two limbs, it's like a kite and the kite angle is between the long axis of the cum and axis of the talus. And uh as you can see here, it's more than 35 degrees. This means this here went into v then you can easily spot. Oh, I'm sorry, you can easily spot uh uh uh from from this side uh from the later side, the uh the me angle which is the angle between longitudinal line, uh longitudinal axis of the talus and the axis, the first ray and navicular. And normally these lines should be either better or within 3 to 4 degrees from each other. If this angle, Mars, Mars angle is booted, this means there is a uh CVAs if negative, this means the PLS. So uh as you can see. So yeah, if the ma angle goes less than four degrees means it's going into negative. This means alanus. If it's increasing, miss it a uh cus then you, you put the Calcaneal Beach which is uh uh a line, a line, a tangential to the inferior edge of the Calcaneum under the ground. And this normally about 16 degree. And if this Calcaneal Beach is decreasing, means this foot is going to be flat. There is the arch, the lateral, no arch is not there anymore. And this gives you an idea that this is a plant. When you do, it's very important to have an oblique views before you can see what we call anti sign or anti sign is means um uh uh calcaneonavicular correlation or abnormal connection. So, anti sign, it means uh abnormal correction between calm and navicular or viar uh correlation, which is the commonest form of correlation. So, if we speak about the adult, as we agree, the most common cause of flat foot in the adult is TPO dysfunction. It's a common cause of adult acquired flat foot. Actually, it's not because the tendon is weak or something, but the tendon is degenerating because we agreed last time that the tendon is, is angling behind the lateral median malar is 90 degrees. And because of this, this makes some watershed area here with low vascularity and easily degenerate. And when it degenerate, the tendon does not function normally again. So there is no more um for uh hind foot inversion or 4 ft abduction. And this is when the patient starts to have a flat foot, he handful foot abduction. The post is normally coming, you know, from be from the back of the tibia fibula and the interosseous membrane, it goes to insert into every bone in the foot in the mid foot except basal first metatarsal. So, navicular uh C three Coors cuboid metatarsal from 2 to 5. So every foot in the tarsal and midtarsal, uh tarsal and the um midtarsal and hind foot except basal first mears the function again. So it blunt flex the ankle, it invert the hind foot and it abduct the choper joint and is definitely the most important dynamic stabilizer of the, the this is Johnson and Trump, which has been modified by, by, by me. Uh So Mr has modified this added the stage of what we call the deltoid level insufficiency and uh ankle fungus. So as you can see, basically, you can differentiate it into four stage stage number one, which there is no deformity. It's just the tendon is painful and, and, and, and there is tenosynovitis, there is nothing in the radiograph. The the foot is normally plante grade stage two, which is flexible, flat foot. Stage three, which is rigid, flat foot and stage four when the ankle start to come into the equation. So stage two, we has into ABC. So from stage two, there is a deformity is, but in stage two, it is still flexible. In stage three, it is rigid uh or uh or, or fix it. In stage two, the flexible deformity number eight, the hind foot only, but the midfoot and forefoot are normal. Number two, mean the forefoot start to abduct. Number three means the midfoot come into the equation and the forefoot is abducted and subin stage three is a high four rigid deformity. So it's fix it, no, no movement anymore. And stage four where uh me had added is when the dito ligament become compromised and the ankle itself goes into valgus, how to manage to take boost dysfunction. So it depends on the stage, you have to start with conservative rules which in the form of uh some support our support orthotics, some uh stitch, um, stretch, uh uh exercises to the tendon and, and uh, and for the calf muscles, uh some resting, some ice. Uh If the tender sign of ice is evident from pain management, you have to start with this, you have to host a conservative measure before you do anything else. If you're still in stage one or what you do is to rest to the tendon until the tenno synovitis improves. So insoles with our support or he wedges ankle, foot, ankle, uh ankle, foot orthos TPO debridement in case that it's severe tenosynovitis and severely painful, you can go arthroscopically. So there is TPO arthroscope to go and um debride the tendon if we, if we speak about the stage two and the stage two, that as we agreed is a flexible deformity. You still again, try not over the stage in the form of orthotics and we do not arch uh hi hinged uh ankle, foot orthos. Uh And at the stage after that, if your problem is in the hind foot, you can do at o if the problem goes to the subb of the midfoot, you can do um uh F DL transfer to the tendon to, to tibialis booster. So you get the FDL tendon to do the job of the posterior, you insert the FDL into the navicular. So it does the same job of the tibialis booster. And at the same time, you can um you can uh tighten the spring ligament to act on the spring ligament anti post to correct the deformity of the mid foot. And definitely, as we agreed, every deform everything for every surgery for the flat foot, you have to lengthen either the achilles or to do approximate gastroc release according to your C score. Is it positive or negative if you plan to correct intraoperative, this is your order of correction. You firstly starting with the either gastro release or a recession uh or a lensing depending on the se you correct the hind foot, you go in order. So you correct the hind foot by medializing calcium hysterotomy, which gets your calcaneum under the tibia. So correct to the line of a, the axis of your hind foot. Then after that, you have the option to do an arthra screw. I'm sorry, this is mistaken. It's not arthrodesis, arthrosis, arthrosis means you bought a screw and there's a sinus sign which moves the whole subtalar, maintain the whole subtalar into virus. So correct the he valgus and you keep it for some time until uh all the tissues start to scar and you, you get it out. It's not a very common practice at the moment but was very common practice in the old days. And it's still a good pa common practice in beats. Then you do do either a TPO three construction. If you can, if not, you do an FDA transfer to replace the tibia, posterior tendon. You do a spring ligament, uh uh repair to maintain, shorten the spring ligament. You take at least from the spring ligament and tighten the spring ligament. So you can get the whole arch back to normal. And if you still have a problem with the forefoot, you can do an lying of the lateral colon by uh events osteotomy, either through the left of the calcemia or the cuboid or you can blunt the flex in the first day through a co osteotomy. So basically, you antagonize uh the deformity, the the the deforming force, then if the patient have arthritis. So the only option is to do a fusion. If the joint is arthritic, there is nobody to do any reconstruction. If we go to stage three, deformity become rigid. So the option we have is to do fusion, we try to be as conservative as we can. So if we need to do a double fusion, that's fine. If we need to do a triple fusion, that's fine, double. So basically you as you have three joints, subtalar arter anchor kidney void, you may be fusing two of them or three of them. And if we go and stage four, when the ankle become in the equation, you have an option. If the ankle is not badly athletic, to just lengthen your achilles and do altoid ligament reconstruction. If the ankle become athletic, you have to combine the table fusion with an ankle replacement if we come to the commonest cause of flat foot in pediatrics. So, tibialis, posterial dysfunction, obesity, I posterior TB tibialis, tendon insufficiency is the commonest cause in adult. If we come to flat foot. In pediatric, the normal is the the communist is stars correlation. And in simple terms, tarsal coalition is failure of differentiation of the tarsal bone. So the tarsal bone maintain fused when they should not be, it could be fib just fibrous coal car core or osseous coalition patient will come to to you with a complaint of recurrent pain and sprains. So it always become symptomatic. When the vision start is the normal joint is the normal uh bones starts to grow as normal. And then that's why ligaments become more stiffer. So the vision should have the no movement from a normal joint. But because the joint between the Tulsa bone is not normal and the the the Tulsa bones are fused. Vision starts to be symptomatic with pain or recurrent sprains. Patient sometimes is paid for over the TSA coalition side because it's weak, bony or fibrous or cartilaginous. Or sometimes if the Tsa Coral is bony, patient doesn't complain from the site of coalition but complain from the mal alignment of the whole foot to examine the patient. Normal examination of any flat foot, the the entire circulation, you will find that the flat foot is rigid. So whatever the patient do a hair, right, the the heel doesn't correct from valgus to virus because it is rigid and the subtalar is not stopping anymore. The types is either uh calcaneonavicular or ter calm. The communist is calcaneal navicular. 90% always symptom become symptomatic at an early age to 8 to 12 compared to 12 to 16. Anterior. As you see, as we say, say before uh anterior sign in uh anterior versus calcaneum is start to be fused with navicular or if you have Ater calcaneum um correlation, you will see what we call C sign. So this patient, if see sign, you can spot it easily, you differentiate, this is normal, this is C sign and this is uh if you have in the circulation, it's actually see sign here as well. So the elbow see sign, you just mark it. Uh And here you say anti sign. Uh CT is a must, you have to have a CT to understand the bony coalition. Is it? Uh how much of the of the, of the joint between the tarsa bone is has in a coalition? Could be a whole, whole service is correlated or just part of it. And this will differentiate will come to an uh in, in account when we go for a surgical treatment, then if you are not sure about the Tulsa correlation as a bony one, you know, you have no way to get um a more I be better idea about fibers or cars except if you do an MRI scan your treatment again, you will exhaust no a treatment stretching by physio, he inserts immobilized. And if no option, you have to operate in this point. I know it's beyond you a bit. But you need to understand that you operate based on the symptoms of the, if the vision is symptomatic from the mal alignment, so you aim to realign the hind foot and the, and, and the forefoot. If the patient complain from the tsar coalition side, this is when we speak about how much coalition is there. So if the patient complaining from, from coalition site, I will have a look in a simple terms if the coalition is less than 50% so I will go resect the tarsal coalition and put some interposition there either thin either fat just to get the joint moving again. If the, if the tarsal coalition is taking more than 50% of the joint, so there is no point to reconstruct, it's easier to make this coalition into a complete fusion or asteroides. So the patient is away from vein. So again, if the patient is painful over the tarsal coalition site, you will deal with the TSA coalition according to the CT, if less than 50%. So I will take the coalition off, maintain the joints. Again, both of interposition with factor tendon. If the TSA coalition is more than 50% I will complete it to a complete arthrodesis or fusion. If it become, it's more than 50%. It's definitely worse prognosis because this is very young patients. Our approach, if we are approaching a ocal will go from median. If we approaching a, we will go from, from lateral. And this is some of the common question in M CQ in part one. Thank you so much. Uh I couldn't make it shorter than this. I need, I need to help you finishing the whole course in a good time before your exam. That's why I'm a bit. Um I'm I'm taking time. I'm sorry for that. And um I hope um uh it was a useful lecture. I'm I'm happy to get any question. Uh Why? Sorry, I just stopped sharing, stop breathing. Yeah. Uh Ahmed is asking why ation gets frequent sprains. So basically it gets frequent sprains because uh there is one joint is not moving. So if you walk, normally you walk through all your joints. So ankle subtalar and midfoot joints are all working. Yeah, if I stop your subtalar joints, I put more stress on your ankle joint and the subtle, the main function of the subtalar is to accommodate the ground and walking. If you don't have this accommodation of the ground and walking, this puts virus or vars stress in your ankle. That's why this patient is always having as sprains again for you to normally walk, you have to have a sub ankle subtalar and made for joints. And the most important in the walking is the subtalar because it allows you to accommodate the ground you're walking on. If you have this subtalar fixed or fused or coal, this means the subtalar is not working. So you're stressing the ankle and the midfoot more than normal. Added to that, you cannot accommodate the ground by your, your subtalar as normal. That's why you need to accommodate the ground by your ankle, which moves your ankle into varus with vagus stress. That's why this patient comes to you always with uh complain of frequent sprains. Any more questions, guys, more questions. OK. Um I hope it, it was useful. Um The video will be available on uh mid all please and please and please uh both your feedback. Once you get uh the link, you should have got the link by now. So once you have the link from mid all, both your feedback, I'm I'm accommodating all both of the negative feedback, all your feedbacks will be taken into account. Um This will help me to modify the next decisions. Um uh Next Friday. Unfortunately, I will not be there because we have the uh Egyptian or Association Congress in Egypt. Um So we'll be off next week, then we'll be back in the week after um Kartik. Thank you so much. Yeah, I asked you just um watch your feedback when you have it and um yeah, you're always welcome. Uh guys. Very good luck. Um Have a look on the video understand what you need to understand. Again, it's my mobile number and, uh, my email, if you have any questions which you didn't get a chance to ask. I'm more than happy to receive your question either by phone or by email and, and, um, yeah, wish you all the best and have a good evening and we'll see you in two weeks on a Friday. Good luck and see you all. Bye.